Download Board Meeting August 2007, Item 5.2 Attachment 2

HEAT: Access
Target: By the end of December 2007 no patient
will wait longer than 18 weeks from GP referral to
an outpatient appointment.
Performance Measure: Outpatient Waiting Times
over 18 weeks
A.04T
3.07.K
Commentary on Progress
The position at the end of June shows a small improvement on the previous month,
both in a reduced number of patients waiting over 18 weeks and a smaller variance
from trajectory. However there remains a significant variance from the planned
performance at the end of June.
Outpatients
waiting >18 weeks
Actual
Trajectory
Variance
April 07
750
655
95
May 07
782
570
212
June 07
676
487
189
The 3 specialities with the most significant variances above their planned June 2007
trajectory are detailed below. These have been discussed with the National Access
Support Team (NAST), and it has been agreed that revised trajectories can be
submitted on the basis of robust recovery action plans.
Orthopaedics
Actual
Trajectory
Variance
April 07
337
160
177
May 07
336
160
176
June 07
335
160
175
This speciality has the most significant variance from plan. This is a combination of
increased referrals and a recent short-term vacancy created by a consultant
retirement. The department plan to undertake an additional 16 new outpatient clinics
during August to December 2007, and the replacement consultant will see an
increased number of new patients. Revised LDP trajectories will be agreed with
NAST and then used for future monitoring.
Urology
Actual
Trajectory
Variance
April 07
50
23
27
May 07
45
18
27
June 07
58
13
45
This speciality has been under significant pressure, particularly in the delivery of
cancer waiting times. Funding was allocated for a fixed term Staff grade post to
provide support, but this has seen 4 staff changes in the last 18 months. A “see and
treat” package has therefore been agreed with the Murrayfield Hospital in Edinburgh
for 100 new outpatients. Again, revised LDP trajectories will be agreed with NAST
and then used for future monitoring.
Commentary on Progress Continued
Orthodontics
Actual
Trajectory
Variance
April 07
78
60
18
May 07
71
50
21
June 07
78
40
38
For the past couple of months, a significant focus of the resources within this
speciality have been on reducing the treatments times for patients who have already
undergone consultation. This has made a significant reduction to this backlog of
patients and resources will now be redirected to new outpatient appointments. We
are confident that performance will now be in line with planned trajectories.
HEAT: Access
Target: Women who have breast cancer and need
urgent treatment will get it within one month where
appropriate.
Performance Measure: % of patients diagnosed
with breast cancer treated within 31 days.
A.08T
3.11.K
Commentary on Progress
Breast Cancer
Breast Cancer had been identified as an area which was experiencing capacity
difficulties with increasing waiting times for both one stop clinics and treatment. The
Highland Breast team have experienced a significant increase in the number of
referrals to the service. In addition, there have been difficulties in the recruitment of
a breast physician, now resolved, which had a detrimental impact on clinic capacity.
A local diagnostic peer review visit was undertaken in February 2007, with the final
report of the Breast Services review issued in April 2007. A Highland–wide Action
Plan in response to the recommendations has been submitted to the Scottish
Executive Health Department (SEHD), and a Highland-wide meeting to agree a
Highland Breast Service model and the implementation detail of the high-level action
plan took place 10 July 2007.
Before the completion of the review, following a number of extra clinics, and
temporary increase in the number of surgical sessions, the position for both the
maximum wait for women who have breast cancer and require urgent treatment, and
the maximum wait from GP urgent referral for breast cancer to treatment have
improved significantly.
Further work is required to agree a pan-Highland Breast Cancer Pathway, to ensure
the timeliness of outpatient assessment and access to triple diagnosis, although it
has been acknowledged that the limitations of the Highland geography may result in
this not always being carried out at a single stop clinic. There is absolute agreement
from all clinicians that the triple assessment diagnosis and access to treatment must
not be delayed and any new pathway will be in line with the SIGN guidance. There
remain delays in theatre capacity with re-modelling currently underway, which will
identify the need for further sessional capacity.
Progress against the recommendations will be monitored within Highland through the
weekly Cancer Performance Support Team meetings.
All Cancers
The waiting time for urgent GP referrals to treatment had been generally
disappointing across Highland. This had been due to a number of systemic
problems across the patient journey which resulted in longer than 62 days for
treatment in many cases. There has been detailed analysis of these common
problems with resolution to a number of areas which were common to many cancers.
Improvements have been significant in access to urgent outpatient appointments,
diagnostic imaging and access to radiotherapy treatment. These improvements have
been complimented with detailed work in each cancer site with the development of
times milestone pathways for each service. The development of a comprehensive
cancer tracking tool, the development of the cancer tracker role and the weekly
review of all patients on a targeted list has resulted in a shorter wait time
improvement for more patients who have, or think they may have, cancer.
In addition to Breast cancer the early priority has been to target effort the other three
largest cancer groups - Lung, Colorectal and Urology.
Progress in Tumour specific sites
Table 1 demonstrates the ISD validated performance for the 2005 Target for each
tumour site for each of the reported quarters in 2006.
Q2 2006
%
59.1%
Q3 2006
%
63%
Q4 2006
Q1 2007 (excl A & B)
63%
69% unvalidated
64.3%
47%
79.2%
87.5% unvalidated
63.6
30%
44.4%
41.7% unvalidated
100
76.2
100%
94%
66.7%
75%
100% unvalidated
72.2% unvalidated
Colorectal
93.3
64%
61.1%
89.5% unvalidated
Head & Neck
33.3
71%
66.7%
33.3% unvalidated
Skin
100
50%
42.9%
100% unvalidated
Upper GI – OG
66.7
79%
55.6%
57.1% unvalidated
Upper GI – HPB
50
100%
88.9%
60% unvalidated
Gynae - Ovarian
100
87.5%
100%
100% unvalidated
Haematology
Lymphoma
71.4
73%
83.3%
Breast 2001 (31 Day
Target)
Breast
62-day
2005 target
Urology
Prostate
Urology
Bladder
Lung
100% unvalidated
Lung Cancer
The Lead Clinician has led improvement initiatives as part of the multidisciplinary
team which ensure that all patients are seen immediately and tracked through the
system in detail.
The development of a 62-day lung pathway taking account of Highland and out-of
area tertiary care is agreed and in place. The implementation of a dedicated Lung
Cancer Clinic has radically streamlined referral into the pathway with a timely
diagnosis facilitated by direct access to CT appointments through collaboration with
diagnostic imaging. This enables efficient and necessary sequencing of the CT scan
ahead of the bronchoscopy tests.
There is a weekly joint MDT meeting
videoconferencing with the respiratory Surgeons in Grampian to support patient
management. Delays in access to PET scanning prior to surgery have had a
detrimental impact on performance in the last quarter, delaying the pathway for
patients to definitive treatment. It is anticipated that the previous good achievement
of lung cancer waiting times will be restored when the new PET capacity is
commissioned in the West of Scotland.
Colorectal Cancer
Focused work led by the Lead Consultant has helped implement a range of
improvements which have directly improved delays for patients. A comprehensive
62-day Colorectal pathway is in place with a multi-site videoconferencing weekly
multi-disciplinary team meeting involving clinicians from Raigmore, Belford,
Caithness Hospitals and colleagues from the Western Isles.
The development of a protocol-based electronic referral, endorsed by GP Committee,
will have a positive impact on the appropriateness and timeliness of referrals. There
is now strict vetting criteria for identifying patients for fast tracking supported by all
Consultants. Urgent cases are shared on common endoscopy lists with physicians,
with the local development of the role of Nurse Endoscopist. In conjunction with the
diagnostic imaging team there are now protected CT slots for rapid diagnosis.
Development of the role of tracker and team leader ensure the weekly monitoring of
patient delays via the cancer tracking tool with remedial action taken to expedite
appointments and treatment. In order to increase consultant capacity there is more
follow up now being undertaken by the clinical nurse specialists.
These sustainable changes have lead to a marked improvement in access times for
colorectal patients in the last quarter.
Urology Cancers
Improving performance in prostate cancer waiting times has been most challenging.
Detailed review of the patient pathway identified significant delays being highlighted
at many stages of the patient journey, which resulted in the majority of patients with
prostate cancer breaching 62 days before treatment. Problems identified included
delays in referral, access to rapid urgent first appointments and subsequent delays to
staging and treatment.
Following engagement of the whole multi-disciplinary team a detailed 62-day
pathway timeline has been agreed for patients who are referred with a possibility of
prostate cancer with processes to support now being implemented.
Investment in the Clinical Nurse Specialist team has enabled a dedicated Nurse-led
TRUS and Biopsy Clinic to allow opportunity for patients to come straight to test.
Improvements in the reporting of histology and access to bone scanning have
resulted in a shorter pathway to treatment for patients.
A significant increase in the number of patient undergoing radical prostatectomy has
had a detrimental impact on the availability of theatre capacity, but theatre modelling
is currently underway to ensure that extra sessional capacity is identified. In the
meantime the option to access see and treat support from outwith NHS Highland is
being explored.
Engagement with Primary Care clinicians via the protected learning time has
provided the basis for progressing a more streamlined referral system with clear
advice on referral criteria. The NOSCAN MCN for Uro-oncology has prioritised work
around referral protocols which will be integrated into local pathways.
There have not yet been demonstrable improvements in the waiting times for
prostate cancer, but the team are confident that the initiatives agreed will have a
positive impact in the next quarter.
Other Cancer Sites
Head and Neck
A pilot is underway in conjunction with the Consultants to encourage use of Cancer
Tracking Tool information, and timely response to identified delays at key milestones
eg time to first appointment, time to diagnosis.
Lymphoma
A 62-day pathway is agreed and being implemented. Haematology is one of the
core services managed by the new SSU Cancer Services Manager, and a range of
priorities around clinic facilities, access to inpatient beds, cancer audit coverage will
inform, and be informed by, the oncology initiatives discussed earlier.
Oesophageal/Gastric
A 62-day pathway is in draft, formal sign off pending. Joint initiatives with the
Colorectal Team have enabled implementation of a range of improvements which
have directly improved delays for patients. These include refinement on the criteria
for identifying patients for fast tracking and shared Endoscopy lists with surgeons and
a specialist Nurse Endoscopist. Further initiatives include the development of Nurseled sessions for patients with oesophageal stents.
Skin Cancer – Melanoma
Diagnosis and treatment is often completed at patient’s first appointment either with
GP or consultant.
Ovarian Cancer
Weekly joint-MDT in place with Grampian Gynaecology-oncology team. Key role in
place from the Gynaecology CNS to the pre-diagnostic and diagnostic stages of the
pathway.
Recruitment to current Consultant vacancies within the Specialism across the
NOSCAN are being addressed.
Other Support Services
Diagnostics
The work driven by the National Diagnostic Collaborative has shown dramatic
improvements in the time patients wait to access tests. Detailed capacity and
demand analysis resulting in the appointment to two new Radiology Consultant
posts, radical redesign of the pathways and dedicated access to procedures will
provide sustainability to these imaging improvements. The Cancer Network and the
Diagnostic Project have worked together to shape and embed fast-track referral
routes for patients with suspected cancer.
Oncology
A fundamental review of Oncology Services has integrated the work of a number of
ongoing initiatives. A dedicated Cancer Services Manager has been appointed to
provide more focused and integrated management of the Oncology Department,
Haematology and Breast services.
The review of Chemotherapy Services has resulted in agreement of the minimum
standards of care and treatment across Highland, and which will guide the safe
ongoing delivery of Chemotherapy Services, and the appropriate development of
new remote chemotherapy services.
A comprehensive review of current Radiotherapy access, in advance of the
commissioning of a second linear accelerator, has prompted streamlining of patient
pathways for patients requiring consultation, and treatment planning, radical or
palliative treatment. A recent Demand and Capacity analysis has resulted in the
implementation of a number of key recommendations around patient flow, prioritised
professional workloads and the redesign of roles and responsibilities. In addition,
extra capacity has been developed locally by the co-operation of radiographic and
physics staff to ensure that there is no delay to patient treatment.
The review of utilisation of Oncology acute inpatient beds has highlighted the need to
tighten criteria for admission, set minimum standards of care and treatment, and
whole system solutions involving GPs and the CNS specialists in the community.
Laboratories
The majority of patients who have cancer are diagnosed by way of Pathology
(approximately 90%), therefore, timely access to reports is an essential part of the
pathway. The Pathology Consultants have a key role as members of the cancer
multi-disciplinary team. Significant efforts have been made to ensure that timely
reports are available to aid or confirm diagnosis, with the electronic Results
Reporting System operational from July, via SCI Store. The procurement of a
replacement electronic system has been delayed and recent focussed effort has
accelerated this with implementation planned in quarter 2 of 2008/2009.
Equipment to improve tissue-processing have been prioritised in the recent
submission to NOSCAN Capital allocation, currently awaiting formal sign-off by the
SEHD.
Theatres
The lack of a day surgery unit in the main acute hospital puts significant pressure on
the main theatres which are currently working at full capacity. The development of a
dedicated day surgery unit has been agreed, but will not be commissioned until early
2010.
The experience and learning from the theatre-modelling approach taken to achieve
the 18 week target has now been applied to take account of projected cancer surgery
with the development of early rota of theatre capacity to ensure the correct balance
of specialty access. Any additional weekly sessions are being released in main
theatre suite with a detailed review of current usage. There is a plan for the visiting
Vanguard mobile theatre unit to assist with this capacity problem.
Information
Access to robust and ‘real time’ data collection and analysis has been vital, and NHS
Highland has developed an electronic patient management system to facilitate the
clinical pathway for patients who have, or might have, cancer. This intranet-based
multi-user Cancer Tracking Tool (CTT) captures waiting times information in a realtime basis, and informs action to help proactively manage patients through to timely
diagnosis and/or treatment across the whole of Highland.
Workforce Planning
Close monitoring, review and necessary redesign of current diagnostic and tumour
specific pathways, will continue. Directed effort in robust Workforce Planning will
begin to future proof cancer services in Highland, and the already evident need to
exploit opportunities for role enhancement of non medical staff continues to be
reinforced.
Patient Involvement
Cancer patients, carers and lay representatives influence services through their
direct involvement at the Cancer steering group, local meetings, through feedback to
clinical services, and in local community forums.
Intensive Support
NHS Highland has been receiving intensive support from the Scottish Executive’s
Cancer Performance Support team (CPST) and undertake a weekly monitoring
meeting with the Executive Lead for Cancer, Cancer Network Manager, and SSU
General Manager and Cancer Services Manager.
Most of the CPST recommendations in the high-level Action Plan have now been
achieved. Out of Area Protocols have been agreed with NHS Grampian and with
NHS Western Isles. A protocol with NHS Greater Glasgow & Clyde has yet to be
progressed.
The SEHD have made capital resources available to NHS Highland to assist in the
local teams managing each of the nine tumour sites making improvements in eg,
time to first appointment and time to diagnosis.
Summary
All cancer pathways span a range of departments and NHS Highland are ensuring
that any improvements take account of the complex interface of the various systems.
Detailed review of all patient pathways and changes in the delivery of support
services has had an immediate impact. The provision of clinicians and management
teams with accurate, real-time information, and their continued engagement in the
regular scrutiny of that information, has facilitated immediate remedial action for
many patients across all pathways.
Whilst improvements have been initially slow, weekly review of evidence now shows
an increasing number of GP urgent referral patients who are being treated for cancer
within 62 days. It is expected that this improvement will be sustained and improved,
with increasing confidence in the delivery of the 31 and 62 day targets across all
cancer sites.
Target: By the end of 2007 patients will wait no
more than 9 weeks for any MRI or CT scans and
other key diagnostic tests
Performance Measure: Waiting Times For
Diagnostic Scopes
A.12T
3.26.K
Commentary on Progress
The draft position for the end of June 2007 is that 48 patients will be waiting over 9
weeks. We had planned that by this stage no patients would be waiting, and we are
required to have no patients waiting by the earlier target date of 1 August 2007. The
distribution of the 48 patients is detailed below.
No of patients SSU
waiting > 9 weeks
0
Upper GI
3
Lower GI
2
Colonoscopy
5
Cystoscopy
10
Total
Mid
CHP
6
North
CHP
14
Total
2
0
6
14
3
7
0
24
5
9
11
48
23
Mid Highland CHP scored red for Lower GI because, although there are only 2 patients
waiting over 9 weeks, the longest wait is 17 weeks.
The table above shows the actual number of patients waiting over 9 weeks by test.
North CHP has the most significant pressures which have arisen due to a consultant
vacancy. The new appointment takes up post in August and plans are in place to
ensure that no patient will be waiting over 9 weeks at the end of July. These plans
include retraining of one of the existing consultants, pooled waiting lists and
additional capacity. Across Highland there are now only 6 patients left to book in
order to meet the end of July deadline, and plans are being put in place to ensure
these patients are seen by the end of the month.
HEAT: Treatment
National Targets: For 2007/2008
 To reduce to zero patients delayed over 6
weeks
 To reduce to zero those delayed in short stay
beds
Performance Measure: Patients experiencing a
delay in discharge where the delay was 6 weeks or
more.
T.01T
4.01.K
Commentary on Progress
The NHS Highland target is proving challenging but achievable. Within the Highland
Partnership several factors are emerging, these are limited care home availability,
the option of choice being exercised (5 patients) and the lack of specialist beds (3
patients) is impacting on progress.
Whilst in Argyll and Bute there has been a slight increase in numbers reflecting a
demand peak rather than a trend. Examples of issues coming together to cause this
are an increase in emergency admissions from the community into care homes
reducing availability for those leaving hospital, self-funders reaching thresholds and
requiring LA funding and the failure of an appeal which means a return of that case to
the list. It is anticipated that this figure will now decrease again.
SOUTH EAST CHP
HEAT: Efficiency
Target: 80% of complaints responded to within 4
weeks
Local
Performance Measure: Completed Complaints –
% of completed complaints resolved within 4 weeks
Commentary on Progress
Compliance was not achieve in the following operating units: SE CHP - 50%
A number of measures are currently being put in place to improve performance and
ensure compliance against the target of 80% of complaints being responded to within
20 days.
These measures are: All complaints letters are to be sent to investigating officers on the day of receipt and
if not possible, certainly within three working days.
Ensuring that Complaints Officers follow up all investigations at 15 days to ensure
that progress is being made.
Holding letters are being send out as soon as it is apparent that the 20 day target is
not going to be achieved
Weekly meetings with the Complaints Officers and the Head of Clinical Governance
and Risk Management to review all complaints at 15 days and to agree course of
action.